October 03, 2011

Puerto Rico Colegio sues insurers By Kelly Soderlund, ADA News staff

San Juan, Puerto Rico—The Puerto Rico College of Dental Surgeons (the Colegio) has filed a $150 million class action lawsuit against most of the insurance companies in Puerto Rico, alleging that dentists have been paid late or not at all, were not paid interest and that services were downcoded or bundled, among other allegations. Dr. Thomas Medina, president of the Colegio, said the insurance companies have created a system that interferes with the doctor-patient relationship. Since 96 percent of the Puerto Rican population holds some type of insurance, it makes it difficult for dentists to provide proper care when they’re trying to finance the overhead of their practice while waiting to be paid by the insurance companies, he said. “Dentists are fed up,” Dr. Medina said. “They cannot survive anymore with the situation in Puerto Rico. The result is that dentists are leaving the island.” The lawsuit accuses the insurance companies of limiting or denying payment for services considered by dentists to be medically necessary. Dr. Medina

“The defendants limit the services that the dentists can offer for financial reasons to the detriment of the dentists’ professional responsibility and practice and to the detriment of the patients,” the lawsuit states. “So much so that the defendants routinely and automatically deny payments without inquiring or analyzing the dental necessity of the procedure performed.” The class consists of the 1,300 members of the Colegio. Puerto Rican law requires membership in the Colegio for a person to practice dentistry in the country, said Edna Hernandez, attorney for the class. The lawsuit was filed in state court in February 2009 and was moved to federal court, where it is pending after the defendants asked the court that it be dismissed, Ms. Hernandez said. The defendants include Triple Management Inc., Triple S Inc., Triple C Inc., American Health Inc., Auxilio Platino Inc., Connecticut General Life Insurance Co. (otherwise known as Cigna Health Care), La Cruz Azul de Puerto Rico Inc., Delta Dental Plan of Puerto Rico Inc., First Medical Health Plan of Puerto Rico Inc., International Medical Card Inc., Humana Health Plans of Puerto Rico Inc., Humana Insurance of Puerto Rico Inc., MCS Health Management Options Inc., MCS Advantage Inc., Metropolitan Life Insurance Co., Option Health Medical Care Network Inc., SDM Health Management Inc., Mennonite General Hospital Inc., Mapfre Life

Insurance Co., MMM Health Care Inc. and Life Insurance Cooperative of Puerto Rico. Puerto Rico does not have a government office that handles provider insurance, Dr. Medina pointed out. There is an insurance commissioner but that office deals with the relationship between the patient and the insurance company. There is no government agency to take this issue to, thus the lawsuit, Dr. Medina said. “We need to change the system as it is in terms of the relationship between providers and insurance companies. There has to be a system or a committee where the parties can sit down and discuss the issues that are important for the providers,” Dr. Medina said. “There are some insurance companies in Puerto Rico that have not changed their fees in 16 years,” Dr. Medina said. The class is seeking recovery to compensate the dentists who suffered economic harm as a result of lack of payment, late payments, bundling and downcoding, Ms. Hernandez said. “We urge all the dentists that if they need any information about this lawsuit or have any information to come forward,” Dr. Medina said. “The Colegio will keep defending the interests of all our members.” For more information, visit www.ccdpr.org or call 1-787-764-7969. Copyright © 1995-2010 American Dental Association. Reproduction or republication strictly prohibited without prior written permission.